news item: “while you were puking…” (SSRI risky during pregnancy)

Today’s post ended up evolving into something of a guest post from Ms Future PharmD, with an assist from yours truly. It has been really interesting and illuminating getting to know the expertise that is out there on the blogroll this way. Every one of us has something unique to offer, from both personal and professional knowledge. So if you see something interesting in the news, on any relevant topic that interests you, please send it to us with your thoughts here. Similarly, if you have a site suggestion, don’t hesitate to drop us a line here.

In this post, we examine a recent blurb from Babble discussing the risk of SSRI during pregnancy. We recognize that within this community, the incidence of anxiety and depression related to infertility, loss, and pregnancy are likely higher than the general population of similar demographics. PAIL recommends that you always consult with your healthcare professional to choose a treatment path that is right for you, your child, and your circumstances – whatever that path is. Please take care of yourself, and understand that others are trying to do the same.

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Last week, Ms Future PharmD emailed us about an “article” (it’s a paragraph at best – let’s call it a blurb) about SSRI (selective serotonin re-uptake inhibitor) use during pregnancy, complete with evidence trail leading back to the clinical study. To say this piqued my curiousity both personally and professionally is an understatement. I have mentioned before that I dealt with crippling anxiety during my pregnancy with HGB, but may not have confided that I subsequently went on an SSRI (an agonizing decision made while breastfeeding) to treat severe PPD afterwards. (Please feel free to email me if you would like to know more about this experience and the choices I had to make – I have not blogged about it to date). I have also mentioned that in my professional life, I use clinical drug trials to support brand messaging for pharmaceuticals (albeit for a different audience than the general public, 90% of the time). When I read the Babble blurb on SSRI use during pregnancy, I immediately saw the problem. Ms Future PharmD had this to say when she initially contacted us:

Here’s the trail of discovery: first I read it at a Babble article (yes, I should stop…) This is the article the Babble author references. Here’s the actual study (freely accessible) – via Human Reproduction It seems to have been addressed in a pile of regular newspapers as well as some TV news outlets. Here’s one from a Boston TV news station.

I also saw it pop in my Twitter feed via Postpartum Progress here and again at Babble here (both pieces by Katherine Stone @ Postpartum Progress and both worthwhile reads in my opinion). So, what is causing all the stir? Here is the original blurb from Babble, in its entirity:

SSRI Risky During Pregnancy

According to a new study, “there is clear and concerning evidence of risk with the use of the SSRI antidepressants by pregnant women, [and] that these drugs lead to worsened pregnancy outcomes.” Additionally, there is no evidence at all of any benefits of using these antidepressants during pregnancy — not for the mother or the baby. Source; Medical Xpress

I have written here before about the actual importance and validity of “a new study” and the perceived importance and validity of ” a new study” by the general public as reported to them in the mass media. To say that it is watered down, with the “key messages” distilled into a single soundbite i s putting it mildly, but right above this paragraph is a shining example (e.g. what are the definitions for “outcomes” and “benefits?”). Alarmism, with a dash of no actual imformation makes for a one-sided, and frankly potentially damaging blurb. To find out exactly what “the study” measured, one would have to click on the source (which is again, a study summary, and not the actual study). How many readers are likely to do this? (Which, to be clear, is not a statement on the intelligence of the average reader, but simply the amount of time available to flesh out the message that was just consumed.) As it turns out, the study is actually a meta-analysis of existing literature chosen by the researchers and examined for common themes. In other words, nothing was actually empirically measured in a clinical setting. At this point, I begin to see red and have a hard time separating my professional distate from my personal outrage and experiences.

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Ms Future Pharm D dissected the summary AND the clinical paper for us, adding in her thoughts:

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Preface: I’m not your doctor, or a doctor at all, so this doesn’t count as medical advice. See your own doctor or get a referral to a specialist if you have questions about your own health. SSRIs are a group of medications used to treat depression and anxiety that might do something to serotonin levels in your brain but we aren’t sure yet exactly how they work. Popular ones are Proz.ac (fluoxetine) and Zo.loft (sertraline) although there are a whole bunch of diverse drugs in the class.

One of the things that makes me really mad about this article is the things it isn’t telling you. It doesn’t really have anything new to say. All of science says that SSRI antidepressants are helpful for some people and not for others (publication bias or not). This isn’t new, yet this article gets all excited about it as if this is something new. (Sidenote: publication bias means that if your study doesn’t find your drug beneficial, you don’t publish it, but it gets reported to the FDA. This article reviews all the studies, not just the published ones. Having no access to unpublished articles, we don’t know if the only reason they weren’t published was that the findings weren’t positive. There could be other problems too.) All of our research says that CBT (cognitive behavioral therapy a.k.a. talk therapy) is as beneficial as or more beneficial than SSRIs alone. That’s not new either.

The big things that are missing from the (second, summary) article are an explanation of the magnitude of effects seen, or how big a deal it is that the SSRI changes pregnancy outcomes. There’s a higher risk of cardiac defects, yes. The difference is 0.09% with no SSRI or 0.1% with it. Is that fundamentally different? Probably not. How much shorter are pregnancies when the mom takes an SSRI? The article makes a big fuss about how gestation is shorter but never admits how much shorter (it’s less than a week shorter). They mention an increased risk of miscarriage, but again skip mentioning how much higher. In one of the studies they cite, the SSRI-taking women had a 13% miscarriage rate and those without had a rate of 8%. The usually accepted miscarriage rate is 12-15% in the population, so that isn’t actually evidence that the SSRIs had a thing to do with it.

When we get to the section specifically on SSRIs and infertility, the authors conclude that we should study it more because the evidence is sparse and that sperm counts might be affected by SSRI usage. Yes, there’s one study that showed that couples treated for depression while undergoing infertility treatment got pregnant at much higher rates, but it was published in a not-so-reputable journal (not a good sign of its credibility) and it only sampled 140 couples (hardly enough to conclude anything about every infertility patient everywhere, other than to say treating mental health is important). All this fuss and the real conclusion is that we should study it more? News media, read the article.

This article also spends a lot of time talking about how SSRI use is associated with negative outcomes in pregnancy (hypertension for example). That tells us not much about whether the SSRI is being used because the pregnant person is otherwise at increased risk of hypertension (say due to anxiety or obesity or something else) or if the SSRI causes the hypertension, and since most studies are done after the pregnancy ends (retrospectively), there’s no way to really know. Likewise, perhaps someone with a history of loss gets depressed and then an SSRI. Does the next miscarriage really have to do with the SSRI? It’s hard to know without a whole lot more study.

The biggest thing left out of this article is what happens in depressed women who get pregnant and aren’t treated at all for depression. The outcomes are worse than those in women taking SSRIs and include more miscarriages and preterm births.

The thing that makes me the most upset reading this article is the focus on the fetus. Yep, fetuses are important if you’re trying to have a baby (duh) but so are mothers. Nowhere does the article talk about the incidence of postpartum depression or psychosis in mothers treated with SSRIs or CBT (it’s lower based on the research we have). Nowhere does it talk about quality of life for depressed pregnant mothers who are untreated, or her support people. Nowhere does it talk about the long-term consequences to relationships of women being untreated or possibly undertreated for depression/anxiety during pregnancy. Untreated depression is not a pretty thing and that’s why we treat it. Treatment of some sort is probably a really good idea if it was in place before pregnancy and stopping suddenly is not a great idea either (brains are slow to adapt to changing medications that alter their functioning so you have to taper down, and this doesn’t mean the medicine is horrible for you, it means your brain is good at adapting).

Overall I’d say that this article is sensational and doesn’t include literature that is important to the decision on how to treat a woman who’s depressed and is/may become pregnant. The guidance from the leading medical folks is still “consider the risks and benefits carefully before treating or changing treatment.” This article doesn’t change that at all, so if this might be you, be sure you get the treatment you need to be healthy and have a doctor you know is an expert in depression treatment during pregnancy supervising your care. The article does make a good point that it’s important to have a qualified specialist treating pregnant women, especially those with infertility to cope with.

Comments

What a great post! Especially since it dissects the original article and adds in the FACTS. I took Zoloft post partum for crippling Post Partum Anxiety. After spending 2 years trying to get pregnant and then 9 months waiting for the other shoe to drop, I was in denial that I would ever have a baby to care for… My PPA was definitely chemical as I was having physiological responses beyond what I had ever experienced before (shaking, crying, increased heartrate). I went on Zoloft while breastfeeding because it was the only feasible option available to me. I went off prior to TTC #2. I will go back on Zoloft right after #2’s delivery.

For me, going on medication was the only answer. I had been in and out of therapy for our infertility and have always dealt with stress/change by running or doing other healthy activities. It was clear that PPA was not a disorder that I was going to be able to “cure” with talk therapy or other healthy coping mechanisms (and this is coming from a therapist). I talk openly about my experience with post partum anxiety in hopes that it not only encourages other moms to seek help when they need it, but also to open people’s eyes to the deep effects infertility can have.

I’m looking forward to seeing what other people have to say about their experiences!

I thankfully didn’t have PPD after Stella was born, but I definitely see how in the ALI community, that is certainly even more prevalent than in the general population. Overall, I just want to say thank you for all of your insights over the past 6 months about not just taking “studies” at face value. They can be like anything else – spun to make the publisher/sponser of the study money. :P This was really interesting!

The thing that always makes mental illness so hard is that the illness itself makes you think that nothing is wrong, or not so wrong you need medicating. I recall a customer at the pharmacy where I work who quit a mental health med when she got pregnant (at her OB’s request, without asking the doctor who prescribed it and treated her mental health=bad idea) turn into a zombie and it was so sad (and I didn’t ever see her postpartum because we moved, so sadly there’s no ending). I think we need to remember that mental health is as important as physical health, and our brains hook up to our bodies in all sorts of cool ways and are inseparable. I also think we need to remember that we have mental health professionals on purpose and that if you need one, you should see one and not just your general doctor (yep, said that once, but it bears repeating). I’m not sure what’s up with me right now, but I am sure my OB totally blew off my concerns about my mental health, and it irritates me (ahem…and there’s some crying too, but hey, hormones make me cry a great deal at actually sad things and just because). My experience with PPD wasn’t my own, it belonged to my spouse and was crazy whoa as experiences go, so I can imagine having to go through the PPD along with all the postpartum weirdness (note to self: request spouse consider a guest post about it, since we rarely mention that non-pregnant people get PPD). Ouch.

Broadly, I get upset about science journalism because we have journalism so not everyone needs to read the big bad studies. When the people assigned to summarize them (or who take it upon themselves to do so) do an awful job and have no knowledge of whether the article is leaving out big chunks of things or not, journalism totally fails. It’s sweet that someone asked the authors of this study about their findings, but nobody checked to see how accurate their claims are (not so much, really) or if their study was a good one. I pay for a newspaper because the news is supposed to be filtered for me through eyes trained to weasel out the truth (or now I pay for NPR because newspapers are just awful). Don’t go reporting on stuff without reading and understanding the facts about it first, news media. Really now. There are interns to write summaries if you’re so lazy you can’t do it yourself.

I had PPD after Avery was born and it was awful. I spent years waiting to meet and fall in love with my baby, but it didn’t happen that way. It was a painful, guilt ridden experience and one that is discussed even less than IF. Thank you for addressing and sharing this. It does feel better to know that others have gone through it.

One thing my doctor told me that made me realize PPD might be more prevalent with our group is that IF, a difficult pregnancy, bed rest, and anxiety about a pregnancy are all huge factors that up your risk for PPD.

I definitely struggled with anxiety and depression throughout my journey to have my son both while trying and while pregnant. At one point, I did see a therapist after my miscarriage and then ectopic, but I never felt the need to go on antidepressants even though tears and getting upset were a daily thing. I was also incredibly anxious in early pregnancy, but thankfully I was able to quit my job and which helped enormously. There was a point where I was incredibly obsessive about what was safe for me to eat and I knew it was overkill but I couldn’t help it. I thought about it taking something, but I knew I would obsess more about the harm any medication would do to my baby than what I was eating, making it not worth it in my mind. I was very lucky that I didn’t struggle with PPD, especially with all the extra risk factors I had during and before pregnancy.

This was a very interesting and important topic to cover here.It’s maddening that the media tries to boil it down so much and sensationalize topics like this. Mental health of the mother is extremely important.